RACHEL ELLIOTT responds on behalf of the authors:

We thank Dr Bissell for his interest in our article. It is clear that the special edition has sparked a lively debate about the issues of compliance and concordance, and not before time. For those of us working in this important area, it is obvious that there are fundamental differences between the concepts of compliance and concordance. Put simply, concordance refers to a process and any change in compliance or adherence may be one possible outcome of that process. For the uninitiated, this was explained clearly by Dr Weiss and Professor Britten in this edition.

Concordance is a concept that attempts to model a type of prescriber-patient relationship. It is proposed that, in a truly concordant relationship, all the patient’s concerns have been included and the approach to decision-making is explicit, shared and co-operative. In this situation, one could suggest that there should be almost no intentional non-adherence to a resultant drug regimen, as the patient has been involved in developing that regimen. Thus concordance can “facilitate adherent behaviour”. The fact that such a high level of non-adherence is reported in many different therapeutic areas suggests that concordant relationships rarely exist between patients and health care professionals.

When looking at policies to improve adherence to medicines, we have found they are based heavily on a range of assumptions about reasons for non-adherence. The level of concordance that exists between patients and health care providers is considered rarely. Current policies and attitudes to patients’ concerns about medicines treat non-adherence as a “deviant behaviour” rather than as an avoidable failure for both patient and health care professional. Furthermore, interventions to improve adherence do not tend to address concordance, they concentrate on giving patients more information in Britain and on making medicines free in the US.

We maintain our position that health policy must attempt to “influence patient decision making”. This is not suggesting coercion; this is acknowledging where the real power lies. Concordance, where it exists, is about transfer of power, not just information, but the patient has had the power all along. Patients are already making the final decisions about their medicines. We have to acknowledge this, not just involve them more in our decision-making about their care.

In our paper, we are not suggesting that we should return to a coercive “prescriber knows best” strategy. However, it is important not to accept uncritically the concordance concept. We are suggesting that health policy needs urgently to address the real reasons for non-adherence, one probable factor being lack of concordant relationships. Otherwise, we will continue our current practice of prescribing and supplying medicines that end up in a medicine cabinet for years.